cervical incompetence moh abdalla

8/15/2019 Cervical Incompetence Moh Abdalla

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Dr.Mohammed AbdallaDr.Mohammed AbdallaDomiat general hospitalDomiat general hospital

cervicalcervical

incompetenceincompetence


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Cervical incompetence isCervical incompetence is

defined as thedefined as the inability toinability tosupport pregnancy tillsupport pregnancy till

termterm

because of a functional orbecause of a functional orstructural defect of thestructural defect of the

cervixcervix


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Although the efficacy of cerclage for

cervical incompetence

has never been fully confirmedin randomized clinical trials ,the role

of cerclage has been expanded toinclude women with risk factors for

spontaneous preterm birth or

nonreassuring sonographic cervicalfindings in the mid trimester.


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So, before you send your

patient to the theater forcerclage your diagnosis

necessities solid criteriaotherwise many will be

unduly done.


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But unfortunately there isBut unfortunately there is

no consensus about theno consensus about thecervical cut off lengthcervical cut off length

< 25mm< 25mm

OrOr< 15mm< 15mm


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the cervical cut offthe cervical cut off

length inlength in singletonsingletonpregnancypregnancy

Cannot be applied inCannot be applied in

multiplemultiple pregnancy?pregnancy?


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As the risk with CL


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Inconsensus about cutoff

cervical length will resultin the categorization of 5%

to 10% of pregnant womenas having a short cervix.

problem


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As any controversialAs any controversial

issue we have hereissue we have herewhite and black faceswhite and black faces

but always within thebut always within thegrey zone, which lies ingrey zone, which lies in

between, we fall inbetween, we fall indoubt.doubt.


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White face here is thehere is thewomen withwomen with

irrelevant obstetricirrelevant obstetricand gynecologicaland gynecological

history, ashistory, as they needthey needno screening.no screening.


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The black face of the problem isof the problem isrepresented by those who haverepresented by those who have

three or more midtrimesterthree or more midtrimester

losses or preterm births , thelosses or preterm births , thedecision isdecision is

a prophylactic cerclage performeda prophylactic cerclage performedat 13 to 16 weeksat 13 to 16 weeks

of gestationof gestation ..

2


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The grey zone isrepresented here by those

women of low or moderaterisk, and they need serial

ultrasound screening bytransvaginalultrasonography.


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Ultrasound screeningUltrasound screening

if we are going to screen this group ofif we are going to screen this group of

patients with mild to moderate risk :patients with mild to moderate risk :

when to start?when to start?what is the ultrasonic criteriawhat is the ultrasonic criteria

of incompetent cervix?of incompetent cervix?and when to intervent?and when to intervent?


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when to startwhen to start

TVS should not begin

before 16 weeksas the upper portion of the

cervix is not easily

distinguished


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ultrasonic criteria ofultrasonic criteria of

incompetent cervixincompetent cervixMake sure to use proper technique.Make sure to use proper technique.

Knowing what to measure .Knowing what to measure .Know what's normal, and what'sKnow what's normal, and what's

abnormal .abnormal .

Linking cervical assessment toLinking cervical assessment to

gestational age .gestational age .


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proper technique

patients are asked to empty their bladder .patients are asked to empty their bladder .You should identify at the same sagittalYou should identify at the same sagittal

view the internal os, external os, cervicalview the internal os, external os, cervical

canal, and endocervical mucosa.canal, and endocervical mucosa.the probe is slowly withdrawn to avoidthe probe is slowly withdrawn to avoid

false elongation of the cervix.false elongation of the cervix.

The cervical length is measured byThe cervical length is measured byfreezing the screen three separate timesfreezing the screen three separate times

with no more than 2 to 3 mm variations.with no more than 2 to 3 mm variations.


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proper technique

To recognize funneling the walls of the funnelTo recognize funneling the walls of the funnelare formed by endocervical mucosa.are formed by endocervical mucosa.

If the cervical canal is sometimes curved,If the cervical canal is sometimes curved,

therefore, cervical length should be determinedtherefore, cervical length should be determined

by tracing the length of the cervix or by addingby tracing the length of the cervix or by addingthe sum of two straight sections.the sum of two straight sections.

Apply transfundal pressure for 15 seconds,Apply transfundal pressure for 15 seconds,

and record any changes in cervical length orand record any changes in cervical length or

funneling. cervical stress test .funneling. cervical stress test .


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cm 2

1.5

1.2


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cervical stresscervical stresstesttest


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the walls of the funnel are formed by

endocervical mucosa.


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what's normalwhat's normal

In low-risk women, CL duringIn low-risk women, CL during

pregnancy has a mean ofpregnancy has a mean of35 to 4035 to 40

mm from 14 to 30 weeksmm from 14 to 30 weeks..the lower 10th percentile beingthe lower 10th percentile being

25 mm and the upper 10th (90th25 mm and the upper 10th (90th

percentile) 50 mmpercentile) 50 mm..


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3812521998Heath et al

421751997Tongsong et al

41411996Cook et al

3529151996Iams et al

371061995Iams et al

421541994Zorzoli et al

371771993Murakawa et al

42771991Andersen et al

48241990Kushnir et al

411251990Andersen et al

48801988Podobnik et al

521501988Ayers et alCervical Length (mm)NYearReference

CERVICAL LENGTH (MEAN OR MEDIAN) IN LOW-RISK POPULATIONS IN MIDTRIMESTER


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9747998151424Hassan etal

995299581523Heath et al

99391006251822Taipale etal

97269723


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Low %PPV meansLow %PPV means

that many unduethat many undue

cerclages werecerclages were

done.done.


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high %NPV meanshigh %NPV meansthat the test isthat the test is

reassuring whenreassuring when

negative.negative.


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So we cannot rely onSo we cannot rely oncervical lengthcervical length

alone as a predictoralone as a predictor

of incompetenceof incompetence


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the progressive shorteningthe progressive shortening

detected by serial sonar,detected by serial sonar,funneling (width and length),funneling (width and length),v-shaped lower uterine segmentv-shaped lower uterine segment

and dynamic cervical changesand dynamic cervical changeswith fundal or suprapubicwith fundal or suprapubicpressure.pressure.

What are the most

important?


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1 2

3 4


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bulging of the membranes in the vagina. The

fetal lower limb protruded into the vagina.


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But how to avoidBut how to avoidundue cerclageundue cerclage

andand

how not to miss ahow not to miss acase?case?


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RISK ASSESMENT>=3 unexplained

second-trimester losses

or preterm deliveries.

Elective Cerclage

at 14-16 wk.

No riskfactor

routine ultrasound

screening of the

cervix is not

recommended


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Can a cervicalCan a cervical

cerclage be used tocerclage be used to

prevent pretermprevent pretermdelivery in patientsdelivery in patients

with a short cervix orwith a short cervix orfunneling?funneling?


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263116Obstetricianuncertainty

12921993MRC/RCOG

6.75.5


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results of randomizedresults of randomized

clinical trials suggest thatclinical trials suggest that

cerclage either had acerclage either had a

modest effect on reducingmodest effect on reducing

the rate of preterm deliverythe rate of preterm deliveryor no effect whatsoeveror no effect whatsoever..

RANDOMIZED STUDIES OFELECTIVE CERVICAL CERCLAGE


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Key pointsKey pointsThe high negative predictiveThe high negative predictive

value for preterm birthvalue for preterm birth

associated with a long cervixassociated with a long cervixand with the absence ofand with the absence of

funneling has important clinicalfunneling has important clinicalimplications in symptomaticimplications in symptomatic

patients.patients.


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Using TVU to assess CL is anUsing TVU to assess CL is an

effective way to predict PTB andeffective way to predict PTB and

"incompetent cervix," now better"incompetent cervix," now betternamed cervical insufficiency. It'snamed cervical insufficiency. It's

safe and patients accept thesafe and patients accept theexamination well.examination well.

Key pointsKey points


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Screening frequency shouldScreening frequency should

depend on severity of obstetricdepend on severity of obstetric

history, with serial TVU of thehistory, with serial TVU of thecervix having a better predictivecervix having a better predictive

accuracy than one, especially inaccuracy than one, especially inhigh-risk populations.high-risk populations.



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screening high-risk women withscreening high-risk women with

TVU of the cervix and placementTVU of the cervix and placement

of a cerclage for the short orof a cerclage for the short orfunneled cervix should not befunneled cervix should not be

considered standard care untilconsidered standard care until

proven by properly conducted,proven by properly conducted,large randomized trialslarge randomized trials



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ThankThankyouyou

cervical incompetence moh abdalla

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